http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(4): 431–435 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.918601

ORIGINAL ARTICLE

Exercise and yoga during pregnancy: a survey J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Hong Kong Libraries on 05/08/15 For personal use only.

Shilpa Babbar1 and Suneet P. Chauhan2 1

Department of Obstetrics and Gynecology, Truman Medical Center Hospital Hill, Kansas City, MO, USA and 2Department of Obstetrics and Gynecology, Lyndon B. Johnson General Hospital, Houston, TX, USA Abstract

Keywords

The primary objective of this survey was to ascertain the opinions, practices and knowledge about exercise, including yoga, during pregnancy; the secondary objective to compare the responses among women with body mass index (BMI) 530 kg/m2 versus 30 kg/m2. Survey consisted of 20 multiple choice questions assessing demographics and exercise practices, and five questions testing their knowledge about it during pregnancy (ACOG Committee Opinion # 267). Of the 500 surveys distributed, 84% (422) responses were analyzed. While 86% of women responded that exercise during pregnancy is beneficial, 83% felt it was beneficial to start prior to pregnancy, and walking was considered the most beneficial (62%). The majority (64%) of respondents were currently exercising during pregnancy and 51% exercised 2–3 times/week. Among the five questions testing knowledge about prenatal exercise, majority (range 60 to 92%) were aware of ACOG recommendations. About half had a BMI 30. Knowledge about benefits of exercise during pregnancy did not differ significantly between obese and non-obese. Yoga was tried significantly more among non-obese, 65% believed it is beneficial, and 40% had attempted yoga before pregnancy. In our population, the majority believes that exercise, including yoga, is beneficial and they are active.

BMI, exercise during pregnancy, prenatal exercise, yoga

Introduction Exercise during pregnancy is beneficial. The purported benefits of physical activities during pregnancy include reducing the risk of gestational diabetes [1], improving mental health and delivery outcomes, while ensuring that weight gain during pregnancy is consistent with the guidelines [2,3]. As noted by the Institute of Medicine guidelines on gestational weight gain (GWG) during pregnancy, over 50% of women gain in excess of the recommendations [4]. While there are several reasons for excessive GWG [4], a possible explanation is that women infrequently exercise during pregnancy [5] and may avoid new regimens that could be beneficial. Yoga has become an increasingly popular exercise in the United States and is practiced by over 20 million Americans [6]. Preliminary studies have demonstrated several benefits during pregnancy including a reduction in labor pain, preterm birth, anxiety, depression and pregnancy complications [7,8]. Thus, it is important for clinicians and researchers to be aware of the type and frequency of physical activities women undertake during pregnancy and their awareness of ACOG recommendations on exercise while pregnant [9].

Address for correspondence: Shilpa Babbar, MD, Department of Obstetrics and Gynecology, Truman Medical Center Hospital Hill, 2301 Holmes Street, Kansas City, MO 64108, USA. Tel: 816-404-5169. E-mail: [email protected]

History Received 3 December 2013 Accepted 23 April 2014 Published online 27 May 2014

The primary purpose of this survey was to ascertain the opinions and current practice of exercise during pregnancy in our population. The secondary purposes were: to assess how knowledgeable our patients are of ACOG recommendations [9] regarding exercise during pregnancy; if the physical activities differ among obese (body mass index [BMI] 30 kg/m2) versus non-obese (BMI 530); and the familiarity and willingness to participate in prenatal yoga.

Materials and methods After receiving an approval from the Institutional Review Board (11-01-XX-0022) at Eastern Virginia Medical School in Norfolk, Virginia, a preprinted cover letter, 25 questions survey and an envelope were distributed to 500 anonymous and voluntary pregnant women at their antenatal visits. The cover letter explained the purpose of the survey, provided instructions, and a disclaimer informing the patient that the only personal health identification information on the survey was the date of their visit; this was combined with their reported estimated due date to calculate their gestational age. Women over the age of 18 years who understood English were eligible to participate in the survey. Demographic data on age, ethnicity, education, employment status, marital status, parity, height and weight were self-reported; verification with their medical records was not performed due to the anonymity of the survey. Of the 25 questions, four focused on demographics, 10 inquired about their exercise habits, six

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ascertained their attitude regarding yoga and five assessed their knowledge, based on questions derived from ACOG recommendations. Each participant was advised to choose the single best answer to each question. Once completed, the participant sealed her response in the empty envelope provided and returned it to the research team member. She was then handed an answer key to the five knowledgebased questions with explanations. This study was conducted between March and December 2011. After all the surveys were returned, the sealed envelopes were opened and the results entered in an Excel sheet (Microsoft, Seattle, WA) for analysis. The Chi-squared test for independence, Kolmogorov–Smirnov normality test and Mann–Whitney test were used where appropriate. A p value of 50.05 was considered significant.

Results Of the 500 surveys distributed, 91% (455) of the surveys returned for analysis. We excluded 7% (33) of those returned because the respondents were less than 18 years (n ¼ 13), not pregnant (n ¼ 1), or declared that they were advised not to exercise during this pregnancy (n ¼ 19). Thus, this analysis summarized the response of 422 (84% of distributed surveys) women receiving prenatal care. Our respondents were as likely to be African-American or Caucasian (43% each). The median gestational age of the women was 27 weeks (range 6 to 41 weeks). Almost one-third (30%) were nulliparous and half (47%) were not currently employed. BMI was at least 30 kg/m2 in 56% of the respondents and 18% exceeded 40 kg/m2 (Table 1). With regards to assessing exercise habits, 86% of women considered it to be beneficial during pregnancy, and walking was favored the most (62%). Sixty percent thought that exercise should be for at least 30 min and 46% of women believed exercise should be done daily (Table 2). The majority (64%) of our respondents reported that they were currently exercising during their pregnancy. Of those exercising, home and outdoors were the most common location to exercise (43% each) with 45% performing it 2–3 times/week. The majority (51%) were walking as their exercise and 88% planned to continue exercising after delivery. The most common reason for not exercising was that they were too busy or could not find the time (43%). With respect to prenatal yoga, 65% believed it to be beneficial. Only 40% had tried yoga prior to pregnancy and 44% considered it ‘‘somewhat difficult’’. The majority (65%) felt they would practice yoga during pregnancy if easily accessible and 55% were ‘‘more likely’’ to take yoga classes if it was offered by trained health care provider (Table 2). Among the five questions assessing knowledge about prenatal exercise, the correct responses ranged from 60 to 92%. While 60% knew exercise during pregnancy can prevent gestational diabetes, 92% were aware that an evaluation by a doctor before starting a new exercise during pregnancy is recommended (Table 3). Obesity (BMI  30 kg/m2) was prevalent in 56% of our respondents. The responses for women with BMI530 kg/m2 versus 30 kg/m2, differed significantly for ethnicity (p ¼ 0.012) and highest education level completed

J Matern Fetal Neonatal Med, 2015; 28(4): 431–435

Table 1. Demographics of the respondents. Age (years) 519 20–34 35 or more Trimester First Second Third Race/Ethnicity African-American White Hispanic/Latino Asian/Pacific Island/Native American Other/Prefer not to answer Education Less than high school Completed high school In college Completed college Completed a masters degree or above Employment status Not working Working part time (10–20 h/week) Working full time (20–40 h/week) Working more than 40 h/week Marital status Single Married Divorced Nulliparous Body mass index (kg/m2) Underweight (518.5) Normal weight (18.5–24.9) Overweight (25–29.9) Obese* (30) Class I (30–34.9) Class II (35–39.9) Class III (40)

3% (14) 77% (317) 20% (81) 9% (36) 40% (159) 51% (205) 43% 43% 6% 7% 2%

(185) (186) (24) (29) (8)

6% 33% 19% 31% 10%

(25) (140) (81) (131) (43)

47% 12% 32% 9%

(198) (49) (136) (40)

44% 52% 4% 30%

(183) (220) (17) (124)

1% (2) 18% (71) 25% (97) 24% (92) 14% (53) 18% (70)

Data presented as % (N). Since all respondents did not answer each question and some chose more than one answer, the total N varies. *Overall 56% (215) of the women were obese.

(p ¼ 0.034). For the two groups, the responses differed significantly for only five questions and the results are provided in Table 4. Responses to all the questions assessing knowledge about exercise during pregnancy did not differ significantly for those with a BMI530 kg/m2 versus 30 kg/m2 (p40.05 for all comparisons).

Discussion Since there are several benefits of exercising during pregnancy [1–3], clinicians should be cognizant of women’s knowledge and exercise habits while pregnant. ACOG recommends 30 min or more of moderate intensity exercise a day on most, if not all, days of the week [9]. A national survey by the Center for Disease Control and Prevention, entitled the National Health and Nutrition Examination Survey (NHANES), assessed physical activities during pregnancy from 1999 to 2006. NHANES classified participants as meeting recommendations if they reported at least 150 min/ week of moderate intensity aerobic activity, defined as tasks that caused light sweating or a slight to moderate increase in breathing or heart rate, or 75 min/week of vigorous intensity aerobic activity where heavy sweating or a large

Exercise and yoga

DOI: 10.3109/14767058.2014.918601

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Table 2. Response to exercise questions. 1. Do you think it’s beneficial to start an exercise regimen PRIOR to getting pregnant? A. Yes B. No C. I don’t know 2. Do you think exercise is beneficial or harmful during pregnancy? A. Beneficial B. Harmful C. Neither D. Both E. I don’t know 3. What type of exercise do you think is MOST beneficial during pregnancy? A. Running B. Walking C. Swimming D. Yoga E. None F. Other 4. How often do you think you should exercise in pregnancy? A. Daily B. 2–3 times per week C. Once a week D. A few times per month E. Whenever you feel like it 5. When exercising, the minimum duration of time spent should be: A. 15 min B. 30 min C. 45 min D. 60 min 6. Do you think yoga is a beneficial exercise during pregnancy? A. Yes B. No C. I don’t know 7. Have you ever tried yoga? A. Yes B. No 8. Are you currently exercising during your pregnancy? A. Yes B. No 9. If you ARE NOT exercising during pregnancy, why not? A. Health reasons B. Couldn’t find comfortable clothing or location C. Couldn’t get motivated D. Too busy/No time 10. If you ARE exercising during pregnancy: a) Where do you usually exercise? A. Gym B. Home C. Outdoors D. Organized groups (i.e. prenatal classes) E. Other b) How often do you exercise? A. Daily B. 2–3 times/week C. Weekly D. Other c) Do you plan to continue an exercise program after your delivery? A. Yes B. No C. I don’t know 11. How difficult do you think yoga is? A. Very hard B. Somewhat difficult C. Not difficult

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Table 2. Continued

83% (348) 4% (17) 13% (54)

12.

86% 0% 3% 7% 3%

(364) (0) (14) (31) (12)

13.

2% 62% 21% 15% 0% 1%

(10) (313) (104) (76) (0) (3)

46% 43% 4% 1% 5%

(196) (181) (18) (6) (23)

36% 60% 2% 1%

(152) (253) (9) (5)

14.

15.

16.

D. Easy E. Very Easy Would you be interested in practicing yoga during your pregnancy if it was easily accessible to you? A. Yes B. No C. I don’t know What is your favorite type of exercise? A. Running B. Walking C. Cycling D. Yoga/Pilates E. Swimming F. Other G. None – I do not exercise Does your family/friends/partner exercise on a regular basis? A. Yes B. No How likely would you be to take a yoga class instructed by a trained health care provider (i.e. doctor or nurse) A. More likely B. Indifferent/Doesn’t matter about their background C. Less likely Do any of your relatives/friends/family practice yoga? A. Yes B. No C. I don’t know

9% (34) 2% (7) 65% (273) 17% (72) 18% (74) 7% 51% 4% 6% 22% 6% 2%

(39) (269) (23) (33) (116) (33) (11)

56% (235) 44% (183)

55% (226) 30% (124) 15% (61) 32% (132) 57% (238) 12% (49)

Data presented as % (N). Since all respondents did not answer each question and some chose more than one answer, the total N varies.

65% (271) 3% (13) 32% (135) 40% (169) 60% (251) 64% (265) 36% (152) 20% 3% 35% 43%

(34) (3) (61) (74)

9% 43% 43% 1% 4%

(31) (148) (148) (3) (14)

34% 45% 15% 6%

(101) (134) (43) (18)

88% (309) 2% (8) 9% (33) 6% (25) 44% (173) 39% (155) (continued )

Table 3. Response to knowledge-based questions. 1. During pregnancy, it is safe to exercise every day for at least 30 min or more of moderate exercise. A. True B. False C. Do not know 2. Exercise in pregnancy may prevent Gestational Diabetes (Diabetes occurring only in pregnancy). A. True B. False C. Do not know 3. You should avoid lying flat on your back or prolonged motionless standing during the 2nd and 3rd trimester of pregnancy. A. True B. False C. Do not know 4. Vigorous exercise and participation in sports such as hockey, soccer, or basketball is safe and recommended during pregnancy. A. True B. False C. Do not know 5. You should be evaluated by your doctor before starting a new exercise routine during pregnancy. A. True B. False C. Do not know

76% (317) 4% (16) 20% (84) 60% (249) 8% (34) 32% (134)

72% (300) 4% (17) 23% (97)

2% (10) 87% (363) 10% (43) 92% (387) 1% (5) 6% (27)

Data presented as % (N). Since all respondents did not answer each question and some chose more than one answer, the total N varies. These five questions were derived from the ACOG committee opinion No. 267 (8).

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J Matern Fetal Neonatal Med, 2015; 28(4): 431–435

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Table 4. Response among non-obese versus obese women.

1. What type of exercise do you think is MOST beneficial during pregnancy? A. Running B. Walking C. Swimming D. Yoga E. None F. Other 2. How often do you think you should exercise in pregnancy? A. Daily B. 2–3 times per week C. Once a week D. A few times per month E. Whenever you feel like it 3. When exercising, the minimum duration of time spent should be: A. 15 min B. 30 min C. 45 min D. 60 min 4. Have you ever tried yoga? A. Yes B. No 5. What is your favorite type of exercise? A. Running B. Walking C. Cycling D. Yoga /Pilates E. Swimming F. Other G. None – I do not exercise

BMI530 (N ¼ 170)

BMI  30 (N ¼ 215)

3% 54% 20% 21% 0% 1%

(6) (112) (42) (44) (0) (3)

1% 69% 20% 9% 0% 0%

(3) (174) (50) (23) (0) (0)

50.001

53% 38% 2% 2% 5%

(91) (66) (3) (4) (8)

40% 47% 5% 1% 7%

(87) (101) (11) (2) (15)

0.041

36% 57% 3% 3%

(62) (97) (5) (5)

33% 65% 2% 0%

(71) (139) (4) (0)

0.045

47% (80) 52% (89)

36% (77) 64% (138)

0.028

12% 45% 4% 7% 20% 9% 3%

4% 57% 4% 5% 24% 5% 1%

0.004

(24) (93) (8) (15) (40) (18) (6)

(11) (153) (10) (14) (63) (14) (2)

p

Data presented as % (N). Since all respondents did not answer each question and some chose more than one answer, the total N varies.

increase in breathing or heart rate was obtained. They had several important findings including: a rate of 23% active women meeting the defined guidelines, the most common type of activity was walking (41% of the respondents) and yoga was practiced by 7%. The surveyors suggested that their data could be used to monitor trends [3]. Thus, we sought to determine the current exercise habits in our population. There are three main findings of this study. First, there is a considerable gap between the knowledge about and reported practice of exercise during pregnancy. For example, yoga was considered to be beneficial by 65% of respondents though only 6% actually practiced it. Though over 80% of the respondents opined that it is beneficial to start exercise before and to continue during pregnancy, only 64% reported being active. While 46% responded that exercise should be done daily, only 34% were actually active every day. There was, however, a consistency between opinion and practice on the types of exercise. Specifically, walking and swimming were considered to be the most beneficial (62 and 21%, respectively) and they were practiced most commonly (51 and 22%). According to a prenatal exercise review study by Field [10], low impact aerobic exercises, including swimming and walking, have commonly been studied in pregnancy, which is consistent with our findings. Future studies should focus on how to motivate women to stay physically active during pregnancy. Secondly, we noted that women in our practice are knowledgeable about ACOG recommendations on exercise during pregnancy [9]. The respondents were least cognizant

about the benefits of exercise in the prevention of gestational diabetes (60%) and almost all (92%) knew that their health should be evaluated by a health care provider before beginning an exercise program in pregnancy (Table 3). Such awareness is reassuring and provides an explanation of why the majority of our respondents reported that they exercised during pregnancy. Additional studies are warranted to confirm that the women who are knowledgeable are actually compliant with ACOG recommendation of being physically active for at least 30 min, on most if not all days of the week [9]. Our third finding regarding obese versus non-obese women demonstrated a significant difference in the knowledge about the type of exercises which are most beneficial, as well as its appropriate duration and frequency. Obese women were more likely to think they needed to exercise only 2–3 days per week; however, they were more likely to believe the duration should be at least 30 min when compared to non-obese women. The two groups also differed with their experience with yoga (Table 4). It is noteworthy that the self-reported practice of exercise among those with BMI530 kg/m2 versus 30 kg/m2 did not differ significantly. There were several limitations in our study. First, information utilized for calculating BMI (height and weight) were self-reported before they were measured at their prenatal visit on the day of survey completion. This may have differed from their actual weight, altering their BMI category. Also, pre-pregnancy weight and pregnancy weight gain were not accounted for. Women were provided this survey at any prenatal visit, not necessarily their first prenatal visit.

Exercise and yoga

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DOI: 10.3109/14767058.2014.918601

Therefore, it cannot be determined if these women received education on exercise during pregnancy from their obstetric care providers throughout their prenatal visits, which may have influenced their attitude, gestational weight gain or actual exercise practices. Secondly, with regard to exercises performed, the depth of physiological response was not correlated to gestational weight gain or peripartum outcomes, nor was it assessed. Hence, our results are not comparable to the NHANES results as we could not determine if our patients were meeting national guidelines on exercise intensity. This could possibly explain the higher rate of self-reported exercise in our study. Irrespectively our goal was to assess ACOG recommendations and we demonstrated that our patients were not meeting the ACOG guidelines on duration and frequency of exercise. Thirdly, we believe that response bias is possible. Women who were exercising may have been more inclined to answer the survey when approached. Despite advising each woman to select the single best answer to each question, several respondents chose multiple answers when applicable. All answers were accounted for in our results. Objective confirmation of the survey was not conducted and the veracity was accepted at face value. Despite our limitations, we had several strengths to our study. A large response rate (92%) with 84% of surveys analyzed and a well-represented minority group reflects a diverse representation of our population. Although it may seem like our study had a rather educated and higher socioeconomic cohort than average, our study represented a population where 40% had a high school education or less. According to the US census bureau in 2012, 87% of people over the age of 25 were high school graduates, 57% had some college and 40% had an associates/bachelor’s degree [11]. It is not clear how many women are advised by their physicians not to exercise during pregnancy; however, this study identified a rate of 4%. In comparison to the national survey by the CDC which was based on recall to assess trends, our survey was based on current practices, increasing accuracy. As obesity has been formally recognized as a global epidemic by the World Health Organization [12], comparing results between obese and non-obese women may benefit futures studies. In conclusion, this pilot study identified a large number of women who believed that exercise and yoga are beneficial and they report being active during their pregnancy. There was a knowledge gap between obese and non-obese women with regard to knowing the appropriate frequency and

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duration of exercise. Additional studies are necessary to verify the self-reported responses to exercise and if peripartum outcomes are improved among those compliant with ACOG recommendations. Future studies may include the education of pregnant women on the appropriate frequency and duration of exercise, ways to improve compliance with prenatal exercises, and assessment of other commonly practiced activities, including yoga. Until then our results indicate that a sufficient population is willing to try yoga during pregnancy, thus a randomized controlled trial on prenatal yoga remains feasible.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

References 1. Dye TD, Knox KL, Artal R, et al. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997;146:961–5. 2. Price BB, Amini SB, Kappeler K. Exercise in pregnancy: effect on fitness and obstetric outcomes – a randomized trial. Med Sci Sports Exerc 2012;44:2263–9. 3. Evenson KR, Wen F. National trends in self-reported physical activity and sedentary behaviors among pregnant women: NHANES 1999–2006. Prev Med 2010;50:123–8. 4. Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines; Rasmussen KM, Yaktine AL, eds. Summary of determinants of gestational weight gain. In: Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press (US); 2009. Available from: http://www.ncbi. nlm.nih.gov/books/NBK32822/ [last accessed 12 Aug 2013]. 5. Evenson KR, Pompeii LA. Obstetrician practice patterns and recommendations for physical activity during pregnancy. J Womens Health (Larchmt) 2010;19:1733–40. 6. ‘‘Yoga in America’’. Available from: http://www.prnewswire.com/ news-releases/yoga-journal-releases-2012-yoga-in-america-marketstudy-182263901.html [last accessed 28 July 2013]. 7. Babbar S, Parks-Savage AC, Chauhan SP. Yoga during pregnancy: a review. Am J Perinatol 2012;29:459–64. 8. Rakhshani A, Nagarathna R, Mhaskar R, et al. The effects of yoga in prevention of pregnancy complications in high-risk pregnancies: a randomized controlled trial. Prev Med 2012;55:333–40. 9. Exercise during pregnancy and the postpartum period. ACOG Committee Opinion. No. 267. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002 (Reaffirmed 2009). 10. Field T. Prenatal exercise research. Infant Behav Dev 2012;35: 397–407. 11. Educational Attainment in the United States: 2012. U.S. Census Bureau. Available from: http://www.census.gov/hhes/socdemo/ education/data/cps/2012/tables.html [last accessed 3 Sep 2013]. 12. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev 2007;29:1–5.

Exercise and yoga during pregnancy: a survey.

The primary objective of this survey was to ascertain the opinions, practices and knowledge about exercise, including yoga, during pregnancy; the seco...
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